Racial and social unrest witnessed during 2020 ignited a national conversation about the appropriateness of the use of race in health care algorithms and in the estimation of kidney function in particular. The growing co...Racial and social unrest witnessed during 2020 ignited a national conversation about the appropriateness of the use of race in health care algorithms and in the estimation of kidney function in particular. The growing concerns over the use of race in kidney function-estimating equations prompted the National Kidney Foundation (NKF) and American Society of Nephrology to launch an effort for change by establishing a task force on reassessing the use of race in diagnosing kidney disease. After nearly a year examining the evidence and obtaining testimony from experts and stakeholders, the task force recommended the immediate implementation of the 2020 Chronic Kidney Disease-Epidemiology creatinine equation refit without race in all US laboratories; increased routine use of cystatin C for confirmation of estimated glomerular filtration rate in clinical decision-making and a call for research on glomerular filtration rate estimation with new endogenous filtration markers and on addressing disparities in health and health care. The NKF and American Society of Nephrology strongly encouraged rapid adoption of these new recommendations. Leadership efforts of the NKF have begun to lay the foundation for national implementation through laboratory engagement, clinician awareness, and patient education.
Adv Chronic Kidney Dis
· 2022 Jan · PMID 35690403
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The ETC model proposes to increase access to home dialysis and transplant for patients with ESRD. Implementation of this model is happening while many dialysis organizations are still suffering the far-reaching effects o...The ETC model proposes to increase access to home dialysis and transplant for patients with ESRD. Implementation of this model is happening while many dialysis organizations are still suffering the far-reaching effects of the coronavirus disease 2019 (COVID-19) pandemic. In addition, the model has the potential to negatively affect small and independent dialysis organizations disproportionately. It incentivizes home dialysis over transplant and promotes development of new home dialysis programs, rewards achievement over improvement, and places an excessive burden on small and independent dialysis organizations. Advantages of the program include the focus on self-care as an acceptable alternative to home dialysis for some patients and the potential for some organizations to make improvements in care with increased reimbursements. The authors hope that the Centers for Medicare and Medicaid Services will address many of these concerns in updated rulemaking and guidance.
Three years ago, the Advancing American Kidney Health executive order launched a substantial effort with the goals of delaying the progression of kidney disease while also increasing kidney transplantation and the utiliz...Three years ago, the Advancing American Kidney Health executive order launched a substantial effort with the goals of delaying the progression of kidney disease while also increasing kidney transplantation and the utilization of home dialysis. Included among the initiatives created by this executive order are two new payment models under the supervision of the Centers for Medicare & Medicaid Services Innovation Center. The End Stage Renal Disease Treatment Choices model is a mandatory payment model impacting nephrologists and dialysis providers in many regions across the country. The Kidney Care Choices model offers nephrologists four voluntary options for participation in value-based care. The early experience of two large kidney care organizations highlights the improvements these payment models have demonstrated over prior kidney care payment models while also suggesting additional opportunities for improvement. These models offer nephrologists the opportunity to partner with other providers and deliver patient-centered care across the kidney care continuum. The models represent another step toward value-based care and, if successful, should yield great benefits for patients with kidney disease.
Adv Chronic Kidney Dis
· 2022 Jan · PMID 35690401
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The United States health care system has increasingly embraced value-based programs that reward improved outcomes and lower costs. Health care value, defined as quality per unit cost, was a major goal of the 2010 Patient...The United States health care system has increasingly embraced value-based programs that reward improved outcomes and lower costs. Health care value, defined as quality per unit cost, was a major goal of the 2010 Patient Protection and Affordable Care Act amid high and rising US health care expenditures. Many early value-based programs were specifically designed for patients with end-stage renal disease (ESRD) and targeted toward dialysis facilities, including the ESRD Prospective Payment System, ESRD Quality Incentive Program, and ESRD Seamless Care Organizations. While a great deal of attention has been paid to these ESRD-focused programs, other value-based programs targeted toward hospitals and health systems may also affect the quality and costs of care for a broader population of patients with kidney disease. Value-based care for kidney disease is increasingly relevant in light of the Advancing American Kidney Health initiative, which introduces new value-based payment models: the mandatory ESRD Treatment Choices Model in 2021 and voluntary Kidney Care Choices Model in 2022. In this review article, we summarize the emergence and impact of value-based programs on the quality and costs of kidney care, with a focus on federal programs. Key opportunities in value-based kidney care include shifting the focus toward chronic kidney disease, enhancing population health management capabilities, improving quality measurement, and leveraging programs to advance health equity.
This article describes two new and complementary initiatives from the Center for Medicare and Medicaid Innovation at the Centers for Medicare & Medicaid Services-the ESRD Treatment Choices and Kidney Care Choices Models-...This article describes two new and complementary initiatives from the Center for Medicare and Medicaid Innovation at the Centers for Medicare & Medicaid Services-the ESRD Treatment Choices and Kidney Care Choices Models-which focus on Medicare beneficiaries with CKD and ESRD. These models, or time-limited tests, are aimed at testing whether modifying Medicare payment methodologies, while also rewarding certain clinical outcomes, will improve treatment and outcomes and reduce costs. Together, these initiatives comprise a major part of the larger federal effort to improve the lives of people with kidney disease. The goal of the ESRD Treatment Choices Model is to maintain or improve quality while reducing cost by incentivizing greater use of home dialysis and kidney transplantation. The model aims to do so by adjusting certain payments to nephrologists and other clinicians managing beneficiaries with ESRD (managing clinicians) and ESRD facilities selected to participate in the model. The Kidney Care Choices Model aims to maintain or improve quality while reducing cost through better coordination of care across a larger spectrum of kidney disease, focusing on beneficiaries with CKD stages 4 and 5 and ESRD, to delay the onset of ESRD and improve the transition for Medicare beneficiaries facing the prospect of dialysis. The Centers for Medicare & Medicaid Services is hopeful that these models will inform the future direction of payment policy for this critical Medicare population.
The United States Preventive Services Task Force has no current recommendation to guide primary care physician screening for chronic kidney disease (CKD). This is misaligned with the scope of the CKD public health emerge...The United States Preventive Services Task Force has no current recommendation to guide primary care physician screening for chronic kidney disease (CKD). This is misaligned with the scope of the CKD public health emergency, recommendations from clinical practice guidelines, health spending on CKD, the changing landscape of CKD detection and treatment, and the focus by policymakers on identifying tangible approaches to improving health equity. This review summarizes patient, clinician, health equity, and health system perspectives in support of screening adults with risk factors for CKD. This review concludes with the assessment that the United States Preventive Services Task Force should revisit targeted CKD screening specifically for adults with diabetes and/or hypertension.
Adv Chronic Kidney Dis
· 2021 Nov · PMID 35367028
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Diabetes mellitus (DM) is one of the most common complications after kidney transplantation and is associated with unfavorable outcomes including death. DM can be present before transplant but post-transplant DM (PTDM) r...Diabetes mellitus (DM) is one of the most common complications after kidney transplantation and is associated with unfavorable outcomes including death. DM can be present before transplant but post-transplant DM (PTDM) refers to diabetes that is diagnosed after solid organ transplantation. Despite its high prevalence, optimal treatment to prevent complications of PTDM is unknown. Medical therapy of pre-existent DM or PTDM after transplant is challenging because of frequent interactions between antidiabetic and immunosuppressive agents. There is also frequent need for medication dose adjustments due to residual kidney disease and a higher risk of medication side effects in patients treated with immunosuppressive agents. Sodium-glucose cotransporter 2 inhibitors have demonstrated a favorable cardio-renal profile in patients with DM without a transplant and hence hold great promise in this patient population although there is concern about the higher risk of urinary tract infections. The significant gaps in our understanding of the pathophysiology, diagnosis, and management of DM after kidney transplantation need to be urgently addressed.
Human leukocyte antigen (HLA)-incompatible kidney transplantation offers survival benefit compared with ongoing dialysis. There have been considerable advances in the last decade to allow for increased access to transpla...Human leukocyte antigen (HLA)-incompatible kidney transplantation offers survival benefit compared with ongoing dialysis. There have been considerable advances in the last decade to allow for increased access to transplant for the HLA-sensitized kidney transplant candidates. These include increased priority in the kidney allocation system, kidney paired donation, and novel desensitization strategies. A better understanding of the role of B cells, plasma cells, and complement and inflammatory cytokines in the pathophysiology of HLA antibody-mediated allograft injury has led to the use of novel therapeutics for desensitization and treatment of antibody-mediated rejection. Here we discuss current approaches to kidney transplantation in HLA-sensitized kidney transplant candidates.
Nonkidney solid organ transplants (NKSOTs) are increasing in the United States with improving long-term allograft and patient survival. CKD is prevalent in patients with NKSOT and is associated with increased morbidity a...Nonkidney solid organ transplants (NKSOTs) are increasing in the United States with improving long-term allograft and patient survival. CKD is prevalent in patients with NKSOT and is associated with increased morbidity and mortality especially in those who progress to end-stage kidney disease. Calcineurin inhibitor nephrotoxicity is a main contributor to CKD after NKSOT, but other factors in the pretransplant, peritransplant, and post-transplant period can predispose to progressive kidney dysfunction. The management of CKD after NKSOT generally follows society guidelines for native kidney disease. Kidney-protective and calcineurin inhibitor-sparing immunosuppression has been explored in this population and warrants a discussion with transplant teams. Kidney transplantation in NKSOT recipients remains the kidney replacement therapy of choice for suitable candidates, as it provides a survival benefit over remaining on dialysis.
Young adult kidney transplant recipients experience poorer outcomes. Specifically worse allograft survival has been reported in the United States and worldwide. Pediatric to adult transition-related research has focused...Young adult kidney transplant recipients experience poorer outcomes. Specifically worse allograft survival has been reported in the United States and worldwide. Pediatric to adult transition-related research has focused predominantly on medication nonadherence. However, the cause of worse graft outcomes in young adults is likely due to a multitude of complex factors. Consensus guidelines were issued to guide pediatric and adult transplant teams during the transition process. To what extent these transition guidelines are utilized and their impact on improving outcomes for young adult patients is unclear. The consensus guidelines serve as a useful resource, but investigation of the potential barriers to putting these transition guidelines into practice is lacking. One must consider the unique needs of medically complex patients, financial disincentives to transition programs, paucity of evidence-based data to support individual aspects of a transition program and their impact on transition success, and absence of strategies to address health care disparities, all of which can have a multiplicative risk for this population. Key transition research is needed to yield evidence-based data to support transition practices that are successful and truly improve outcomes in this high-risk transplant population. It will also allow better stewardship of transplant organs by optimizing outcomes and allograft longevity.
The incidence of kidney dysfunction has increased in liver transplant and heart transplant candidates, reflecting a changing patient population and allocation policies that prioritize the most urgent candidates. A higher...The incidence of kidney dysfunction has increased in liver transplant and heart transplant candidates, reflecting a changing patient population and allocation policies that prioritize the most urgent candidates. A higher burden of pretransplant kidney dysfunction has resulted in a substantial rise in the utilization of multiorgan transplantation (MOT). Owing to a shortage of available deceased donor kidneys, the increased use of MOT has the potential to disadvantage kidney-alone transplant candidates, as current allocation policies generally provide priority for MOT candidates above all kidney-alone transplant candidates. In this review, the implications of kidney disease in liver transplant and heart transplant candidates is reviewed, and current policies used to allocate organs are discussed. Important ethical considerations pertaining to MOT allocation are examined, and future policy modifications that may improve both equity and utility in MOT policy are considered.
Transplantation remains the optimal mode of kidney replacement therapy, but unfortunately long-term graft survival after 1 year remains suboptimal. The main mechanism of chronic allograft injury is alloimmune, and curren...Transplantation remains the optimal mode of kidney replacement therapy, but unfortunately long-term graft survival after 1 year remains suboptimal. The main mechanism of chronic allograft injury is alloimmune, and current clinical monitoring of kidney transplants includes measuring serum creatinine, proteinuria, and immunosuppressive drug levels. The most important biomarker routinely monitored is human leukocyte antigen (HLA) donor-specific antibodies (DSAs) with the frequency based on underlying immunologic risk. HLA-DSA should be measured if there is graft dysfunction, immunosuppression minimization, or nonadherence. Antibody strength is semiquantitatively estimated as mean fluorescence intensity, with titration studies for equivocal cases and for following response to treatment. Determination of in vitro C1q or C3d positivity or HLA-DSA IgG subclass analysis remains of uncertain significance, but we do not recommend these for routine use. Current evidence does not support routine monitoring of non-HLA antibodies except anti-angiotensin II type 1 receptor antibodies when the phenotype is appropriate. The monitoring of both donor-derived cell-free DNA in blood or gene expression profiling of serum and/or urine may detect subclinical rejection, although mainly as a supplement and not as a replacement for biopsy. The optimal frequency and cost-effectiveness of using these noninvasive assays remain to be determined. We review the available literature and make recommendations.
Adv Chronic Kidney Dis
· 2021 Nov · PMID 35367022
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Access to transplant centers is a key barrier for kidney transplant evaluation and follow-up care for both the recipient and donor. Potential kidney transplant recipients and living kidney donors may face geographic, fin...Access to transplant centers is a key barrier for kidney transplant evaluation and follow-up care for both the recipient and donor. Potential kidney transplant recipients and living kidney donors may face geographic, financial, and logistical challenges in engaging with a transplant center and maintaining post-transplant continuity of care. Telemedicine via synchronous video visits has the potential to overcome the access barrier to transplant centers. Transplant centers can start the evaluation process for potential recipients and donors via telemedicine, especially for those who have challenges to come for an in-person visit or when there are restrictions on clinic capacities, such as during a pandemic. Similarly, transplant centers can use telemedicine to sustain post-transplant follow-up care while avoiding the burden of travel and its associated costs. However, expansion to telemedicine-based kidney transplant services is substantially dependent on telemedicine infrastructure, insurer policy, and state regulations. In this review, we discuss the practice of telemedicine in kidney transplantation and its implications for expanding access to kidney transplant services and outreach from pretransplant evaluation to post-transplant follow-up care for the recipient and donor.
Adv Chronic Kidney Dis
· 2021 Nov · PMID 35367021
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In this review, we discuss the increasing prevalence of obesity among people with chronic and end-stage kidney disease (ESKD) and implications for kidney transplant (KT) candidate selection and management. Although peopl...In this review, we discuss the increasing prevalence of obesity among people with chronic and end-stage kidney disease (ESKD) and implications for kidney transplant (KT) candidate selection and management. Although people with obesity and ESKD receive survival and quality-of-life benefits from KT, most KT programs maintain strict body mass index (BMI) cutoffs to determine transplant eligibility. However, BMI does not distinguish between visceral adiposity, which confers higher cardiovascular risks and risks of perioperative and adverse posttransplant outcomes, and muscle mass, which is protective in ESKD. Furthermore, requirements for patients with obesity to lose weight before KT should be balanced with the findings of numerous studies that show weight loss is a risk factor for death among patients with ESKD, independent of starting BMI. Data suggest that KT is associated with survival benefits relative to remaining on dialysis for candidates with obesity although recipients without obesity have higher delayed graft function rates and longer transplant hospitalization durations. Research is needed to determine the optimal body composition metrics for KT candidacy assessments and risk stratification. In addition, ESKD-specific obesity management guidelines are needed that will address the neurologic, behavioral, socioeconomic, and physical underpinnings of this increasingly common disease.
Adv Chronic Kidney Dis
· 2021 Nov · PMID 35367020
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Stark racial disparities in access to and receipt of kidney transplantation, especially living donor and pre-emptive transplantation, have persisted despite decades of investigation and intervention. The causes of these...Stark racial disparities in access to and receipt of kidney transplantation, especially living donor and pre-emptive transplantation, have persisted despite decades of investigation and intervention. The causes of these disparities are complex, are inter-related, and result from a cascade of structural barriers to transplantation which disproportionately impact minoritized individuals and communities. Structural barriers contributing to racial transplant inequities have been acknowledged but are often not fully explored with regard to transplant equity. We describe longstanding racial disparities in transplantation, and we discuss contributing structural barriers which occur along the transplant pathway including pretransplant health care, evaluation, referral processes, and the evaluation of transplant candidates. We also consider the role of multilevel socio-contextual influences on these processes. We believe focused efforts which apply an equity lens to key transplant processes and systems are required to achieve greater structural competency and, ultimately, racial transplant equity.
Despite an increase in the number of kidney transplants performed annually, there remain more than 90,000 individuals awaiting transplantation in the United States. As kidney transplantation has evolved, so has kidney al...Despite an increase in the number of kidney transplants performed annually, there remain more than 90,000 individuals awaiting transplantation in the United States. As kidney transplantation has evolved, so has kidney allocation policies. The Kidney Allocation System, which was introduced in 2014, made significant strides to improve utility and equity, but regional and geographic disparities remain. Further modifications eliminating donor service areas have been introduced. Moving forward, systems involving continuous distribution and artificial intelligence may provide further advancement toward an ideal allocation system.
The incidence of cancer is higher in patients with end-stage kidney disease (ESKD) than among the general population. Despite this, screening for cancer is generally not cost-effective and may worsen quality of life in t...The incidence of cancer is higher in patients with end-stage kidney disease (ESKD) than among the general population. Despite this, screening for cancer is generally not cost-effective and may worsen quality of life in these patients. This is due to high mortality rates (patients are not living long enough to reap the benefits of screening), the inaccuracy of cancer screening tests, and the increased risks associated with therapy in patients with ESKD. Specific groups of patients with ESKD who have a longer-than-expected life expectancy or higher-than-expected cancer risk may benefit from screening. These groups include patients on peritoneal dialysis, patients on home hemodialysis, Black and Asian-American patients, transplant-eligible patients, and those at higher risk of cancer including patients with acquired cystic kidney disease, those who have been previously exposed to cytotoxic agents or aristolochic acid, and patients with a genetic predisposition to cancer. In this narrative review, we will examine the prevalence of and risk factors for cancer in patients with ESKD and the effectiveness of cancer screening, and discuss specific situations in which cancer screening may be effective.